Walking through downtown Portland, it’s not unusual to cross paths with some poor soul yelling obscenities into the air while erratically darting among pedestrians.

On the sidewalk outside the Street Roots editorial office in Old Town, the tenor of neighborhood inhabitants speaking to unseen others often varies between incoherent ramblings and highly aggressive shouting throughout the day.

To many people who live or work in areas of the city where homelessness has become increasingly visible in recent years, these sightings are commonplace.

But what exactly are we seeing? An epidemic of severe mental illnesses going untreated or widespread psychosis from drug use, which can occur with heavy or prolonged methamphetamine use in some individuals?

According to police, doctors and service providers, the answer is both. And most often, it’s a combination of the two, with methamphetamine acting as a symptom-provoking culprit.

But even for experts, it’s nearly impossible to initially distinguish between someone who’s psychotic from drug use and someone who’s suffering from mental illness.

“Symptoms of methamphetamine-induced psychosis versus symptoms of mental illness such as schizophrenia or bipolar disorder present very similarly,” said Dr. Anne Gross, medical director of psychiatric emergency services at Unity Center for Behavioral Health. “It’s very difficult to actually differentiate the etiology of psychosis.”

What is clear, however, is that the community isn’t addressing its psychosis problem effectively and people suffering symptoms in the streets aren’t safe. Downtown Portland’s seen at least two fatal incidents during the past month.

Carol Horner, a 70-year-old homeless woman who was known to wander around Old Town talking loudly to herself, was murdered under the Morrison Bridge on Nov. 20. She had been suffering from a diagnosed mental illness.

For Richard Barry, 52, who died in police custody after officers responded to reports of a man yelling and running in the street near Portland State University on Thanksgiving Day, the cause of his behavior was a lethal mixture of methamphetamine and cocaine.

But police didn’t know that when they arrived on the scene.

Just as it is for doctors, the cause of a person’s psychotic symptoms is often a mystery to law enforcement who come into contact with a person behaving erratically.

“You can’t really tell what the driving factor is, and you certainly can’t tell chicken and egg,” said Liesbeth Gerritsen, who coordinates crisis intervention training for the Portland Police Bureau. “Maybe it started as a mental illness, undiagnosed, and now the drugs are a way to self-medicate, to relieve symptoms.”

Alternately, the individual could have a methamphetamine addiction that has affected their brain in a way that they now also have anxiety, depression and other side effects of drug use, she said.

In some cases, meth-induced psychosis can persist long after a person stops using the drug. Sometimes days, weeks, months or even permanently.

Dr. William Hoffman works at the in-patient psychiatry unit at the Portland VA Medical Center. He said, “We see people, and they’re psychotic. They think the FBI is following them, tapping their phone. They think they can hear people talking about them outside their door, that sort of thing, and they are very frightened.”

He said once the drugs are out of the patient’s system and they’ve been clean for a few days, they might say, “Whoa, that was crazy! I can’t believe I thought those things were happening. I’ve got to quit using meth.”

“And then we see them again a few months later,” Hoffman continued, “and it takes a little longer for them to get better. And then we see them again – and sometimes, then, the psychosis never goes away, and they look like somebody who has schizophrenia, basically.”

At Bud Clark Commons, a permanent supportive housing complex in Old Town, Mike Savara said he’s had to call for an ambulance about nine times over the past six months to get help for someone using meth. Savara supervises Central City Concern's medical clinic located within the building that serves some of the tenants who live there.

Across the U.S., amphetamine-related hospitalizations, primarily from methamphetamine, more than tripled between 2008 and 2015, and western states such as Oregon saw the most drastic increase, according to a study published in the Journal of the American Medical Association in October.

Locally, methamphetamine contributed to 46 percent of deaths among Multnomah County’s homeless population last year, according to the county’s 2017 Domicile Unknown report. And Portland Police Bureau seized nearly four times more meth than it did heroin in 2017.

As of Dec. 11 at Oregon State Hospital, 48 percent of the psychiatric hospital’s 609 patients were listed as having a substance use disorder. That’s 8 percent higher than the last time this number was calculated in March 2017.

Savara estimates he comes into contact with someone experiencing meth-induced psychosis on a monthly basis, but said it’s far more common for him to see people who already have an underlying mental health issue that is triggered or exacerbated with meth use.

“If someone has a vulnerability to psychosis or extreme states, and then they use meth, they are going to be likely to experience meth-induced psychosis,” he said.

Hoffman agrees. “If they come into hospital and have a urine drug screen and it’s positive for meth, you can be sure that the meth didn’t make the psychosis any better; it almost surely made it worse.”

•••

But anyone can experience meth-induced psychosis if they take enough of the drug, said Hoffman, who in addition to being a psychiatric unit clinician is a researcher at the Methamphetamine Abuse Research Center, a program of Oregon Health and Science University and the Portland VA.

“There were actually some experiments done in the ‘60s where they gave increasing doses of amphetamine to normal college students, and all of them, after you gave them enough stimulants, started becoming hypervigilant and suspicious and started exhibiting the sorts of prodromal effects of someone who is getting psychotic,” he said.

At the Methamphetamine Abuse Research Center, investigators are working to develop immune and gene therapies that might help counter methamphetamine addiction.

One researcher is examining a drug that could reduce the brain inflammation that methamphetamine use causes. This inflammation of the brain affects a person’s memory and concentration, and it’s believed this is one reason people drop out of treatment.

“They feel terrible,” said Hoffman, “and if they start using meth again, then that terrible feeling goes away. So if you could reduce that feeling that you can’t concentrate, that you can’t remember anything, that you feel foggy using anti-inflammatory drugs, people might stay in treatment longer.”

Hoffman recently wrapped up a three-year study, outside of the center, that was funded through a grant from the U.S. Department of Justice. His hypothesis was that experiencing meth-induced psychosis will increase a person’s likeliness to become involved with the criminal justice system.

“Because,” he said, “people who are psychotic can arguably be imagined to be exercising even worse decision making on a lot of fronts, than people who are not psychotic.”

The study involved about 50 Portlanders in recovery from recent, heavy meth use.

While preliminary findings show an increase in minor crimes such as shoplifting and drug possession as well as interpersonal crimes such as assault, what surprised Hoffman was the high rate at which his subjects reported being crime victims.

“They reported being robbed, assaulted. The women reported really high levels of sexual assault, as well as resorting to prostitution to pay for drugs,” he said.

At times, they were victimized while experiencing methamphetamine-induced psychosis, which about 30 percent to 40 percent of the subjects said they endured.

“Particularly, the women reported assaults while they were psychotic,” Hoffman said.

Researchers know chronic meth psychosis changes the brain in ways similar to schizophrenia, he said, but they don’t know if the mechanisms are exactly the same. “And we probably know more about schizophrenia than we do meth-induced psychosis, just because there are a lot more people who suffer from schizophrenia.”

The cause of meth-psychosis is dopamine – a chemical messenger in the brain that involves reward and memory and regulates movement.

Whenever a person experiences something pleasurable, such as sex, food or even watching a good movie, Hoffman explains, dopamine acts as a signal to the brain that the event is of enhanced importance. In other words, dopamine changes the level of importance your brain assigns to things going on around you. So when meth makes a person high, releasing a lot of dopamine, the user’s brain can begin to assign importance to what would otherwise be mundane occurrences.

“For example,” said Hoffman, “one time a person said, ‘You know doc, the FBI started following me.’ And I said, ‘Well, how do you know?’ That’s the first question you always ask when somebody says something that sounds delusional. And he said, ‘There are these guys in suits and ties that walk by my apartment every day.’”

Hoffman was able to determine that this was because the patient lived next to a large office building.

“So yes, of course, there are people in ties and sport coats walking by his place every day. They don’t have anything to do with him, but his brain – he sees that in his brain as ‘whoa.’”

When your brain decides something unrelated to you is important, he said, “then the brain makes something up to explain that.” It might be that it’s the FBI or police checking up on you, he said, “and the same thing with hallucinations, that’s a misattribution of importance to your own thoughts.”

•••

A few weeks ago, Savara said he had to call 911 when one of his tenants at Bud Clark Commons began waving a knife and running into the street in front of the apartment building.

In a behavioral situation, police bureau trainer Gerritsen explained, whatever the cause, all the bureau’s officers are trained to keep their distance, be patient and try to ascertain if the person has the ability to understand and respond to their commands.

These steps are the core of the model, developed in Memphis, that Portland police have used since 1995. Every officer on the force undergoes 40 hours of this training, and roughly 140 officers have opted to take an additional 40 hours of enhanced crisis intervention training.

“It’s not rocket science,” Gerritsen said. “It’s just that sometimes when things are escalated, it’s hard to remember those things.”

Savara said officers responding to recent mental health emergencies at Bud Clark Commons have remained calm and listened to his advice when approaching tenants.

In the recent case of the woman wielding a knife, he said police kept their distance until they were able to approach her safely from behind, and then talked with her calmly while she waited in cuffs for the ambulance to arrive. Savara said she later tested positive for meth and, upon her return to Bud Clark Commons, said she was grateful she was taken to the Unity Center for help.

While serious and numerous complaints about patient and staff safety at Unity Center have been the source of a recent state investigation into its operations, as reported by the Portland Tribune, it’s the most likely area hospital to keep a patient who’s experiencing meth-induced psychosis for more than just a few hours.

A man waits at Unity Center for Behavioral Health. Patients for whom drug use is a factor and who want to get clean are typically discharged to a waitlist.

Photo courtesy of Unity Center for Behavioral Health

People can arrive at the Unity Center with police, from other hospitals or clinics, or walk in off the street. Gross said suicide ideation is the most common reason people are admitted to the center’s Psychiatric Emergency Services, present in 45 percent of admissions, typically in combination with other factors.

“And many of those people have methamphetamine in their system,” she said. The center, however, does not track data on the number of urine drug screens that test positive for meth, according to its spokesperson.

“Co-morbidity, meaning people who use substances including methamphetamine and struggle with psychiatric illness, like schizophrenia, bipolar disorder, depression – is very common,” said Gross.

Whether the cause is determined to be mental illness, amphetamine use or both, the center will often stabilize the patient in its large, armchair-filled emergency room alongside other patients until their symptoms subside. Gross said the center’s emergency services include single rooms and protective interventions when patients are experiencing agitation or have privacy needs.

All patients are triaged, and treatment plans are developed. Whether their delusions are caused by schizophrenia or meth, they receive the same types of medications, as is common practice. Doctors often begin to treat the symptoms of psychosis without knowing the cause, because even if the patient tests positive for methamphetamine, that does not necessarily mean the drug caused of their psychosis.

Gross said one of the challenges in treating methamphetamine users is that there are no medications specific to amphetamine use disorders.

“So our treatment is symptomatic. We use medication to treat symptoms of psychosis; we use behavioral therapies to treat the other (problems) that they may be experiencing,” she said. “We do feel like we have a lot to offer them.”

But when a contributing factor is drug use and the patient wants to get clean, they’re typically discharged to a waitlist, said Juliana Wallace, director of services at Unity Center.

“There is a tremendous waitlist for the limited residential treatment beds we have in the community,” Wallace said.

Savara said for every 100 patients coming out of Hooper Detox Stabilization Center, there are typically just five residential treatment beds available, leaving clinicians to decide which 5 out of 100 people who just went through the painful process of detoxifying from drugs will get the help they need to stay clean.

He also has a tenant who’s been waiting five months to get into a specialized drug treatment center in Klamath Falls, he said.

The shortage or residential drug treatment beds, said Multnomah County Commissioner Sharon Meieran, is triggered by the Portland metro area’s lack of affordable, supportive housing. Meieran campaigned on a platform of fixing the county’s mental health care system.

She said the limited residential drug and alcohol treatment beds in the county are “virtually always full,” and that patients often stay in those beds longer than necessary “because there is nowhere for them to go, and no one wants to discharge people to the street.”

When a person decides during a hospital visit they are ready to get clean and the opportunity is not readily available, Savara said that’s an opportunity missed.

“That moment is such a powerful moment for change or for connecting them with some kind of new support,” he said. He said he typically sees people discharged from traditional hospitals within three or four hours after they’re admitted for methamphetamine-induced psychosis.

“There is a need that’s not being met,” Savara said. “How do we think in terms of the short term, and a holistic community, what are we doing about this person and how do we keep them from cycling through these different systems and silos and actually getting the right care they need?”

But it’s not residential drug treatment shortages alone that are to blame. The local mental health system has its problems, too.

•••

As an addictions counselor, Savara said he’s heard from people struggling with mental illness that using drugs like meth provides them with an alternative to the emotion-numbing state that psychiatric medications can induce.

Gary Wyffels can relate. When he’s in the manic state of his bipolar disorder, it’s like being on “the best ecstasy and the best cocaine you’ve ever had.” He used to self-medicate with illicit drugs when the depressive state of his disorder began to set in, as a way to get the high back and avoid the crash, he said.

Now he’s sober, taking psychiatric medication and working as an outreach specialist for Dual Diagnosis Anonymous. It’s an organization that he says serves as a rare source of support for people struggling with both a mental illness and a substance abuse disorder, giving them “dual diagnosis.”

Wyffels leads support groups at places such as the Unity Center and inside the downtown jail, based on the 12-step model but with five additional steps that DDA has added to address mental health.

Accessing treatment for people with dual diagnosis can prove virtually impossible in Multnomah County, according to multiple providers interviewed for this story.

Traditional hospitals often discharge patients who use meth as soon as they’re stabilized, sending them back out into the community only to return to an E.R. at a later date when they have another episode.

Providers and people with mental health diagnoses told Street Roots that while mental health facilities point patients with dual diagnosis to drug treatment programs, alcohol and drug treatment facilities point them toward mental health treatment – both sides of the provider spectrum tell the patient they’re ill-equipped to treat them until the other issue is dealt with, leaving the patient without any treatment at all.

County Commissioner Meieran, who initiated the study, said she knows this is an issue.

“The issue is so profound,” Meieran said, “and it intersects with so many different areas of public safety and housing and workforce, and all of these different issues.”

Now that the study has been completed, she said she’s trying to untangle funding sources and their requirements so she can determine if there are more effective ways to utilize mental health care dollars.

She said the county is still in the “idea phase,” but in many ways, she’s attempting to re-imagine what a mental health care system that would serve the county’s most vulnerable would look like.

It might be mental health counselors placed strategically at places in the community where people experiencing homelessness already congregate. It could be a center where people could hang out, paint, read and if they want, get a little mental health counseling.

Angel Prater, executive director at peer-support provider Folk-Time, Inc., thinks investing in peer-run respites might be a solution for some folks dealing with dual diagnosis, rather than traditional psychiatric hospitals that have risk factors determining what policies and procedures are in place.

“They’re done all over the world, but we don’t have any in Oregon,” she said. Everyone who works at these facilities has some level of lived experience, there are more negotiations than rules, and it’s a place where people can go “hit their re-set button” without losing their power, she said.

A recovered methamphetamine user, Prater has experienced psychosis while using the drug, she said. She said that when a person is experiencing these delusions, she knows from her own experiences that being approached by someone who is willing to listen and validate their experience is more powerful than someone who is only interested in telling them what they need to do.

Ultimately, Multnomah County is responsible for the solving the problem – mental health and addictions treatment services are in its portfolio, but it will likely need some help from the city to fully mitigate what’s become a humanitarian crisis.

But as the county struggles with figuring out the right way to handle the problem, resources for new programs just aren’t there. The county has to make 3 percent budget cuts across all its departments in the upcoming budget cycle, Meieran said.

In 2019, however, Multnomah County will be asking Oregon Legislature to increase Health Share’s reimbursements to service providers for drug and alcohol treatment.

While reimbursements to pay for mental health care are already low – Meieran’s study also found the mental health care workforce across the county is “overburdened and underpaid” – reimbursements for drug and alcohol disorder treatments are even lower.

“By bringing those two on par, the hope and expectation would be maybe you can better integrate services to treat both of those conditions,” said Meieran.

Correction: This article originally stated Central City Concern manages Bud Clark Commons. It does not. Regional housing authority Home Forward manages Bud Clark Commons and Central City Concern runs a medical clinic located within the building.

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